Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue
Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
California Employee Waiver Form
For Small Groups
Health care plans offered by Anthem Blue Cross. Insurance plans offered by Anthem Blue Cross Life and Health Insurance Company.
Instructions: Please complete and return to your Group Administrator. You, the employee, must complete this
application. You are solely responsible for its accuracy and completeness. To avoid the possibility of delay, please
answer all questions and be sure to sign and date your application. Note: Anthem Blue Cross (Anthem) is required by
the Internal Revenue Service and Centers for Medicare & Medicaid (CMS) to collect Social Security numbers.
Group/Case no. (if known)
Section 1: Employee Information
Employment status (required)
Full-time Part-time
Hire date (required)
(MM/DD/YYYY)
Occupation/job title (required)
Do you read and write English? Yes No If no, the translator must sign and submit a Statement of Accountability/Translator’s Statement.
Section 2: Waiver/Declining coverage — Complete only if any coverage is declined or refused by you and/or your eligible dependents.
Proof of coverage may be required. (Proof of coverage not applicable for Life and Disability.)
Type of coverage/Declined for: Select all that apply
Reason for declining/refusing coverage: Select all that apply
Medical Dental Vision
Life/AD&D Short Term Disability
Long Term Disability
No coverage
Covered by Spouse’s/Domestic Partner’s group coverage
Spouse/Domestic Partner covered by thier employer’s
group coverage
Enrolled in Individual coverage
Medicare/Medi-Cal/VA
Enrolled in other Insurance — Please provide company
name and plan:
________________________________________
Other — please explain:
________________________________________
Spouse/
Domestic Partner
Medical Dental Vision
Dependent Life
Medical Dental Vision
Dependent Life
List name of dependents to be waived: _____________________
I acknowledge that the available coverages have been explained to me by my employer and I know that I have every right to apply for coverage. I have
been given the chance to apply for this coverage and I have decided not to enroll myself and/or my dependent(s), if any. I have made this decision
voluntarily, and no one, including but not limited to my employer, agent or life carrier, has tried to influence me or put any pressure on me to waive
coverage. BY WAIVING THIS GROUP MEDICAL, DENTAL, VISION, DISABILITY AND/OR LIFE COVERAGE (UNLESS EMPLOYEE AND/OR
DEPENDENTS HAVE GROUP MEDICAL, DENTAL, VISION, DISABILITY AND/OR LIFE COVERAGE ELSEWHERE) I ACKNOWLEDGE THAT MY
DEPENDENTS AND I MAY HAVE TO WAIT UNTIL THE NEXT OPEN ENROLLMENT TO BE ENROLLED IN THIS GROUP’S MEDICAL, DENTAL,
VISION, INSURANCE PLAN UNLESS I QUALIFY FOR A SPECIAL OPEN ENROLLMENT. I also understand that if I wish to apply for Life coverage in
the future, I may be required to provide evidence of insurability at my expense. Please note Spouse/Domestic Partner and Dependent coverage will
not be available if the Employee has waived/declined.
Special Open Enrollment (Not applicable to Life or Disability)
If you declined enrollment for yourself or your dependent(s) (including a spouse/domestic partner), you may be able to enroll yourself or your
dependent(s) in this health benefit plan or change health benefit plans as a result of certain triggering events, including: (1) you or your dependent
loses minimum essential coverage; (2) you gain or become a dependent; (3) you are mandated to be covered as a dependent pursuant to a valid state
or federal court order; (4) you have been released from incarceration; (5) your health coverage issuer substantially violated a material provision of the
health coverage contract; (6) you gain access to new health benefit plans as a result of a permanent move; (7) you were receiving services from a
contracting provider under another health benefit plan, for one of the conditions described in Section 1373.96(c) of the Health and Safety Code and
that provider is no longer participating in the health benefit plan; (8) you are a member of the reserve forces of the United States military or a member
of the California National Guard, and returning from active duty service; or (9) you demonstrate to the department that you did not enroll in a health
benefit plan during the immediately preceding enrollment period because you were misinformed that you were covered under minimum essential
coverage. You must request special enrollment within 60 days from the date of the triggering event to be able to enroll yourself or your dependent(s) in
this health benefit plan or change health benefit plans as a result of a qualifying triggering event.
Signature of applicant if declining coverage for yourself or dependents
X
1 Anthem is required by the Internal Revenue Service and Centers for Medicare & Medicaid (CMS) regulations to collect this information.
click to sign
signature
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